Lung Cancer Screening

There are two major types of lung cancer:

• Non-small cell lung cancer accounts for 85 to 90 percent of lung cancers. The main types of non-small cell lung cancer are:
• Squamous cell carcinoma (also called epidermoid carcinoma) often begins in the bronchi near the middle of the lungs.
• Adenocarcinoma usually begins along the outer edges of the lungs. It is the most common type of lung cancer in people who have never smoked.
• Large cell carcinomas are a group of cancers with large, abnormal-looking cells related to hormone secreting glands. These tumors may begin anywhere in the lungs and grow quickly.
• Small cell lung cancer is sometimes called oat cell cancer. It grows rapidly and spreads to other organs. There are two types:
• Limited. Cancer is generally found in one lung. There may be cancer in nearby lymph nodes on the same side of the chest.
• Extensive. Cancer has spread beyond the primary tumor in the lung into other parts of the body.

Smoking tobacco is the most significant risk for developing this type of cancer, typically affecting people older than 45. Factors that contribute to an increased risk for developing lung cancer include:

• Smoking cigarettes, pipes or cigars, now or in the past
• Secondhand smoke
• Exposure to cancer-causing substances:
• Asbestos
• Radon
• Chromium
• Nickel
• Radioactive ores, such as uranium and plutonium
• Arsenic
• Vinyl chloride
• Silica
• Coal products
• Mustard gas
• Chloromethyl ethers
• Diesel exhaust
• Soot
• Tar
• Personal or family history of lung cancer (first degree relative who developed lung cancer under the age of 60)
• Prior radiation therapy to the chest
• Diet
• Air pollution

Lung cancer may not cause any symptoms and may be found on a routine chest X-ray or low-dose chest CT scan. Signs and symptoms of lung cancer may include:

• Cough that doesn’t go away and worsens over time
• Trouble breathing
• Chest pain
• Wheezing
• Coughing up blood or rust-colored mucus
• Hoarseness
• Loss of appetite
• Weight loss for no known reason
• Feeling very tired
• Pneumonia or bronchitis
• Shoulder pain
• Bone pain
• Yellowing of skin and eyes (jaundice)
• Headache, seizures or confusion
• Enlarged lymph nodes in the neck

Diagnosis of lung cancer often includes a number of different tests and procedures, many conducted by your thoracic surgeon:

• Medical history
• Physical examination
• Blood and urine test
• Chest X-ray to look for any mass or spot on the lungs.
• Computerized tomography scan (CT scan) uses a combination of X-rays and computer technology to produce horizontal, or axial, images of the body.
• Sputum cytology studies phlegm (mucus) cells under a microscope.
• Thoracentesis, a hollow needle inserted through the skin in the chest wall to remove fluid (when present), which is then sent to the lab to be checked for cancer cells.
• Biopsy performed using either a closed or an open method. Closed methods are performed through the skin or through the trachea (windpipe). An open biopsy is performed in the operating room under general anesthesia.
• Needle biopsy, a thin, hollow needle guided into the mass while the lungs are being viewed on a fluoroscopy or CT scan. A sample is removed and evaluated under a microscope. Also called a closed, transthoracic or percutaneous (through the skin) biopsy. A needle biopsy may also be performed during a bronchoscopy (see below).
• Thoracoscopic biopsy, also referred to as video-assisted thoracic surgery (VATS) biopsy, is an operation where the surgeon makes one or more small cuts in the side of the chest wall, under anesthesia, through which a small telescope with a video camera on the end is inserted. This allows the doctor to look at the outer part of the lungs and chest wall and to sample any abnormal areas for viewing under a microscope. Therapeutic procedures, such as the removal of a nodule or other tissue may be performed. This is a surgical procedure necessitating a hospital. Depending on the results of the biopsy, more extensive surgery, such as the removal of a lobe of the lung may be performed during the procedure.
• Bronchoscopy, examination of the bronchi (the main airways of the lungs) using a flexible tube (bronchoscope) passed down the mouth or nose. Bronchoscopy helps to evaluate and diagnose lung problems, assess blockages, obtain samples of tissue and/or fluid and/or to help remove a foreign body.
• Navigational bronchoscopy: This new procedure creates a GPS-type guidance system combined with a bronchoscope to biopsy deeper and smaller spots in the lung.
• Transbronchial biopsy is performed through a fiberoptic bronchoscope (a long, thin tube that has a close-focusing telescope on the end for viewing) through the main airways of the lungs (bronchoscopy).
• Endobronchial ultrasound, a specialized technique combining bronchoscopy with an ultrasound that enables clinicians to visualize lymph nodes with high sensitivity, and allows a biopsy without an incision.
• Mediastinoscopy, a small incision is made in the neck above the top of the sternum under general anesthesia and a mediastinoscope is inserted to see into the chest cavity and obtain tissue samples of mediastinal lymph nodes. This procedure helps in staging the cancer or making the diagnosis of the cancer.

MRI, PET or bone scans determine if the cancer has spread from where it started into other areas of the body. Diagnosis of lung cancer often includes a number of different tests and procedures, many conducted by your thoracic surgeon:

The process used to find out if cancer has spread within the lungs or to other parts of the body is called staging. The stage is determined from the results of physical exams, imaging tests and biopsies that have been done. The process used to find out if cancer has spread within the lungs or to other parts of the body is called staging. The stage is determined from the results of physical exams, imaging tests and biopsies that have been done.

Depending on its type and stage, lung cancer may be treated with surgery, chemotherapy radiation therapy, local ablation including laser therapy or a combination of treatments. Treatment options include:

Surgery

Surgery is usually the best option for treating early-stage lung cancer and may be used to remove a portion of the lung or the entire lung. Our thoracic surgeons have pioneered the use of minimally invasive video-assisted thoracic surgery (VATS), and continue to develop innovative approaches to achieving the best outcomes for lung cancer patients.

Types of Surgery

• Segmental or wedge resection: Removal of only a part of the lung. There are 10 segments in each lung.
• Lobectomy: Removal of an entire lobe of the lung. There are three lobes in the right lung and two in the left lung.
• Pneumonectomy: Removal of an entire lung.
• Sleeve resection: Removal of a piece of bronchus, after which the lung is reattached to the remaining part of the bronchus.
• Open-chest surgery: Open procedures are less common, as minimally invasive surgeries are easier on the patient and equally effective. Sometimes, major open surgery is required, such as when the tumor is very large.

Minimally Invasive Surgery

Using minimally invasive surgery techniques over traditional surgeries offers patients many benefits: improved accuracy and visualization, minimized trauma to tissue, less bleeding, decreased pain, less scarring and a shortened recovery.

• Segmental/wedge resection and lobectomy are both done with minimally invasive surgical procedures that use small incisions and specialized instruments with video-scopes to guide the surgical process. Many patients come to us after learning they are not candidates for traditional surgery, and we are able to provide innovative surgical options that are safe and effective. Surgical techniques include:
• Video-Assisted Thoracic Surgery (VATS), a minimally invasive procedure that involves the insertion of a thoracoscope (a tiny camera) and surgical instruments into small incisions in the chest. Open lung resection for cancer often requires a large thoracotomy incision with spreading of the ribs. VATS lobectomy uses three small incisions without any spreading of the ribs. A camera is used to assist the dissection of sensitive blood vessels and lung structures. Less pain and quicker recovery are the goals. If chemotherapy is necessary after surgery, patients are healthier and can more reliably begin their adjuvant additional therapy.
• Image Guided Video Assisted Thoracoscopic Surgery (IVATS), a new technique pioneered at Brigham and Women’s Hospital where minimally invasive thoracic surgery is combined with live CT scanning in the operating room to precisely pinpoint the location and margins of the nodule or tumor to be removed. This is particularly appropriate for very small suspicious nodules which are otherwise difficult to find during conventional surgery.
• Endoscopic Stent Placement: An endoscope is a thin, tube-like instrument. It may be used to place a stent in an airway blocked by abnormal (cancerous) tissue, helping a patient to breathe more easily.

Non-Surgical Cancer Treatments

Radiation therapy uses high-energy rays to kill or shrink cancer cells. Radiation is often used in conjunction with chemotherapy before surgery to shrink the tumor. Brigham and Women’s Faulkner Hospital’s Department of Radiology uses the most advanced equipment and techniques to deliver radiation to cancerous areas, while avoiding exposure to normal tissues. More importantly, radiation experts work closely with your surgeon to create a specialized treatment plan just for you.

• Brachytherapy: Radiation therapy can be delivered with catheters to precise location to radiate small areas with high energy.
• Stereotactic Body Radiation Therapy (SBRT): Radiation therapy can be delivered into specific small areas with high intensity using innovative computerized machines.
• Chemotherapy: Chemotherapy uses anticancer drugs to kill cancer cells throughout the entire body. Chemotherapy is often used before or after surgery or alone in the most advanced cases of lung cancer. The purpose is to shrink the tumor so it can be surgically removed. Chemotherapy is often used in conjunction with radiation. Chemotherapy experts work closely with your surgeon to create a personalized treatment plan.
• Clinical Trials and Targeted Therapy: Biological drugs now exist that target specific lung tumors based on their genetic makeup. Every tumor is analyzed for its genetic make-up in order to maximize patient benefit and tailor the best therapy for each patient.
• Photodynamic Therapy (PDT): A type of laser treatment that involves injecting photosensitizing chemicals into the bloodstream. For lung cancer, the light is delivered through a bronchoscope inserted through the mouth or nose. PDT is generally used for very early bronchial cancers or advanced cancers blocking an airway.

Please call the Brigham Lung Center at 617-278-0810 for further information or visit the Brigham Lung Center website (opens on the Brigham and Women's website).

The U.S. Preventive Services Task Force (USPSTF) has revised the recommended ages and pack-years for lung cancer screening. They now recommend that adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years:**

• screen for lung cancer with low-dose computed tomography (CT) every year
• stop screening once a person has not smoked for 15 years or has a health problem that limits life expectancy or the ability to have lung surgery.

**Check with your insurance company to see if you are covered for screening.

Speak to your primary care physician to see if you qualify for LCS CT. All patients require a physician order.

The LCS scan reduces the radiation dose to the patient by only scanning the area of the lungs. A normal chest CT scan uses a higher dose to see additional structures such as the heart and mediastinum, which are more difficult to see using low dose techniques. The dose used in a LCS CT is similar to that seen in screening mammograms.

Call the number on the back of your health insurance card and ask a representative about your coverage.

You should be in your best usual state of health. This may include a long-standing cough or shortness of breath due to smoking. The test should not be performed when you have new symptoms, such as fever, chest pain, a new or changing cough, shortness of breath that you have never felt before, coughing up blood, or unexplained weight loss.

Radiation can increase a person’s risk of cancer 20 or more years later. No test, including lung cancer screening CT, is perfect. Important medical conditions, including lung cancer may go undetected. Twenty five to 30 percent of the time, findings may require additional imaging or evaluation. Small lung nodules are very common, and more than 97 percent are not cancer although they can cause anxiety. Repeating the examination in 3 months is the most frequent follow-up exam to track nodules. Occasionally, patients need a procedure such as a biopsy that will only be performed with your informed consent.

Areas of your body next to your lungs are partially imaged. In a small percentage of cases (5 to 10 percent), the CT scan will show an abnormal finding in one of these areas, such as your kidneys, adrenal glands, liver or thyroid. Your healthcare provider who ordered your exam can help determine what, if any, additional testing you may need.

Your healthcare provider who ordered your exam will receive a copy of your results. You can sign up for Patient Gateway to view the results directly.

Brigham and Women's Hospital/Brigham and Women's Faulkner Hospital’s Lung Cancer Screening program is approved by the Massachusetts Department of Public Health Radiation Control Program as a “healing arts screening program.” Additionally, the American College of Radiology recognizes our site as a “designated Lung Cancer Screening Center.” These designations assure our patients that they will receive the very best quality care while minimizing the radiation dose.